Most of complications affecting hospitalized patients today are hospital-acquired (HAI) or nosocomial infections. Steve Harden notes that, “one of the greatest heartbreaks in health care is to go to hospital and pick up a deadly infection from the very place you thought would help you” (Harden, 2010, p.17). More so, according to the author, hospital acquired infections are becoming a threat to the safety of many patients today. It is estimated that HAI occur in about 10 per cent (The Free Dictionary, n.d) of all hospitalized patients (Raftery, 2008, p.162). Defining HAI, Vasanthakumari says that it is infection that develops after a patient is admitted to hospital where it is not present or in incubation at the time of admission to the hospital, and it is only acquired as a result of the hospital stay (Vasanthakumari, 2007). Basically, the commonest forms of HAI are UTIs, wound infections, and lower respiratory tract infections and skin and soft tissue infections (Raftery, 2008, p.162).
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Several factors have been attributed to be the major causes of hospital acquired infection, which include: patients with dysfunctional defence mechanisms as a result of pre-existing diseases like diabetes, immunosuppression and also patients with prosthetic implants and more susceptible to hospital infections; hospital environment which is full of wide variety of organisms (Encyclopedia of Surgery, N.d). In addition, the micro-organisms may be present in contaminated equipment, air, water, food, dust and even the antiseptic lotions; any small or minor lapse in asepsis especially during diagnostic or therapeutic interventions such as insertion of catheters which in turn may introduce infections; inappropriate or improperly screened blood, blood products and other intravenous fluids that are normally used in transfusion again may lead to infection; and lastly, HAI are difficult to treat since the infecting agents are usually multi-drug resistant (Vasanthakumari, 2007).
Historical perspective of Hospital Acquired Infections
Analyzing HAI literature, it is evident that the earliest form of advice with regard to hospital hygiene was written around the fourth century BC, in the Charaka-Samhita, which is a Sanskrit textbook of medicine that borrows heavily on Indian Vedic medicine (Nelson and Williams, 2007, p.507). During the medieval and Renaissance Europe, hospitals were largely overcrowded and personalities like Theodoric of Bologna together with Casper Stromayr tried to put some reforms in the hospital practice by putting in place program of bathing their patients and even shaving the site of operation; unfortunately it experienced little success (Nelson and Williams, 2007, p.507). By the end of 1700s, Madam Necker gave a proposal whereby she envisioned the nursing of sick in a single bed instead of eight patients who were being nursed in one bed amid terrible filth.
Simpson, who was a Scottish surgeon, demonstrated that mortality resulting from amputation was equivalent to the size of hospital and degree of overcrowding; and in the mid of 1800s, Florence Nightingale, after her service in the army hospitals during the Crimean War, published a report which showed that more soldiers succumbed to deaths due to hospital-acquired infections (Nelson and Williams, 2007, p.508). Seeking the help of John Farr, Nightingale showed how a direct relationship existed between sanitary conditions at a hospital and postoperative complications and as a result, she made recommendations that required ward sisters to maintain records of hospital patients who developed infections and at the same time introduced numerous hospital hygiene, hence becoming the pioneer of the concept of nosocomial infection surveillance (Nelson and Williams, 2007, p.508). Furthermore, during the same period Ignatz Semmelweis, the head of obstetrical service at the Royal Lying-In Hospital of Vienna carried out a hospital-based epidemiologic study and his findings indicated that puerperal fever was higher in the ward staffed by physicians (Nelson and Williams, 2007); and when physicians had participated in autopsies of women with puerperal sepsis, they would again return to the wards to give care to the women in labor. From these observations, Ignatz linked the increased rates of puerperal fever to lack of hand washing. Immediately after the study, hand washing was instituted as a control measure and as a result, the ward-specific excess rate of puerperal sepsis and mortality declined (Nelson and Williams, 2007).
Louis Pasteur showed how the air is infected with living germs and using Pasteur’s findings, Lister discovered that microbes were responsible for wound suppuration hence he introduced antisepsis to surgery. A t the same time, in 1895, George Emerson Brewer, who was an American surgeon, discovered the issue of infections especially after surgery which forced him to undertake a major intensive surveillance project with objective to estimate the frequency of SSIs. His findings indicated that SSI rates among patients with clean surgery were actually 39 per cent and not 5 per cent. Subsequently, the findings prompted the review of surgical techniques and environmental risk factors; and in 1915 following a follow-up study, Brewer found out that there was a steady decline of SSIs to 1.2 per cent specifically among patients who were receiving clean surgical procedures (Nelson and Williams, 2007).
Towards the recent times, literature shows that the first infection control practitioner (ICP) was appointed in 1959 in England and was mandated to control hospital-acquired Staphylococcus infections (Nelson and Williams, 2007, p.509). In 1963, USA made some progress by appointing a full-time practitioner to control hospital infections, and in 1964, Boston City carried out the first modern prevalence studies that showed that 15 per cent of inpatients were having nosocomial infections. By the year 1968, CDC was undertaking training for ICPs practitioners in surveillance, prevention, and control of nosocomial infections but on positive note, in 1969, the Joint Commission for Accreditation of Healthcare Organizations instituted all hospital to support an infection control nurse (Nelson and Williams, 2007).
Current issues with Hospital Acquired Infections
Today, HAI are seen as a major challenge that confronts the safety of most patients admitted in hospitals (Peleg and Hooper, 2010). By the year 2002, statistics showed that a total of 1.7 million hospital-acquired infections represented 4.5 per 100 admissions (Peleg and Hooper, 2010). Further, as a result of these infections, it was estimated that 99,000 deaths occurred that positioned hospital-acquired infections at number six as the leading cause of deaths in United States of America (Peleg and Hooper, 2010). More so, these data are almost the same for other European countries whereby the estimated costs incurred as a result of hospital-acquired infections for the USA budget stood at $5 billion and $10 billion every year (Peleg and Hooper, 2010).
Gram-negative bacteria have become the main cause of many HAI and today, it is a big concern to many stakeholders. For instance, these organisms possess great efficiency in regulating and acquiring genes which in turn code for mechanisms of antibiotic drug resistance specifically with the availability of antibiotic selection pressure. Moreover, the organisms demonstrate characteristics of resistance mechanisms where they employ numerous mechanisms against similar antibiotic or on the other hand, utilize a single mechanism to affect numerous antibiotics (Peleg and Hooper, 2010). Accelerating the issue of antimicrobial-drug resistance is the existence of a threat of decrease in invention and advancement of new antibiotics. This problem is catalyzed by several contributory factors: escalating challenges of testing for new compounds; the soaring capital costs and relatively long time needed for any drug to be developed; the rising complexity in designing and conducting definitive clinical trials; and lastly major concern related to decline in drug longevity as a result of emergence of resistance. Due to these, a problem of hospital-acquired infections has been created whereby people are witnessing an increasing drug resistance in absence of new drug development.
Hospital data and comparative data
Santa Clara Valley Medical Center is located in San Jose, California. It has 285-bed capacity and is operated by County of Santa Clara. Of the 285 beds, 228 are in-patient acute beds while 12 are reserved for day cases. The Medical Center operates numerous critical care units including high level neonatal intensive care unit, also the Center is licensed for cardiovascular surgery and cardiac catheterization. Audits reports on the hygiene levels at the Center indicated that in 2007 it was 76 per cent fair and in 2009, it rose to 89 per cent which seemed to be a positive trend. Moreover, Hospital-acquired infections affected 1.8 per cent of the patients in 2008 whereby a Methicillin-resistant Staphylococcus aureus (MRSA) infection rate was 0.11 per 1,000 bed days.
Compared with national statistics on the prevalence of HAI, it is evident that Santa Clara Valley Medical Center has put in place adequate measures to address the issue of HAI. According to The New England Journal of Medicine, statistics show that “between 5 and 10 percent of the patients who are admitted to U.S. acute-care hospitals acquire one or more infections there, and the risks have steadily increased in recent decades” (FOCUS, N.d). Recent studies undertaken in emerging infectious diseases (EID) show that HAI are placed at sixth position in causing deaths in USA and cost associated with the infections is estimated to be around $6 billion every year. A CDC study carried out and published in recent times shows that Methicillin-resistant Staphylococcus aureus which is one of the numerous superbugs is the most prevalent and that cases of MRSA tripled between 2000 and 2005 and today 94,360 people are infected while 18650 succumb to death every year.
Chosen HAI data to improve
In USA, it is estimated that 2.7 per cent of all surgical sites get infected and as a result, 500,000 SSIs occur every year. Evidence shows that surgical sites remain the common type of infection where it is believed 5 per cent of all surgery patients get infected (Goldstein, 2010). As a result, concern for SSIs has increased due to numerous reasons. First, patients who get infected with SSI normally requires considerable amount of extra medical care than someone who did not. When there is a case of SSI injury, it has been identified that a patient is 60 per cent as likely to spend time in Intensive Care after surgery compared to an individual with no such issue (Goldstein, 2010). Also patients with SSI have to make arrangements of an extended hospital stay of about two weeks minimum while at the same time they are five times more likely to get readmission to the hospital. But it is the danger that is associated with SSI that of death when the complication accelerates, which makes it necessary for the hospital to make necessary improvements in surgical sites.
Plan to improve surgical site infections
As a result of focus on SSI, the Santa Clara Valley Medical Center will initiate a Six Sigma project which is a well outlined plan to reduce the risks of postoperative infections. Six Sigma program establishes objectives first in order to avoid derailment in the project and some of the indicators to be employed will include: recommended antibiotic that is appropriate for specific surgery; dose administration at the right time; administration of right dose based on weight; appropriate intraoperative re-dose if the surgery is long; and discontinuing the prophylactic antibiotic within 24 hours of surgery. The aim of Six Sigma will be to limit errors and defects to the lowest minimal cases.
Financial impacts of HAI
Financial statistics associated with hospital-acquired infections are alarming. For example studies in forty USA hospitals between 1998 and 2006 indicate that, sepsis and pneumonia claimed 48,000 people and increased health care cost by $8.1 billion (Kaissi, 2010). Furthermore, patients who got infected by sepsis after undergoing surgery had to extent their stay in hospital for another eleven days increasing their cost to $33,000 per every patient (Kaissi, 2010) and as a result almost 20 per cent patients died. Those patients who were infected by pneumonia after surgery extended their stay in hospital by fourteen days the subsequent cost increased by $46,000 per every patient (Kaissi, 2010) and as a result 11 per cent of these patients did not survive. Therefore it is evident that the financial burden posed by HAI is enormous and costly.
Goals of TJC and CMS
TJC has pioneered medication standards that are associated with HAI while CMS has established and facilitated rules and regulations on hospital-acquired conditions. For instance CMS proposed a new rule regarding withholding additional Medicare payments for hospital acquired conditions and for now CMS does not pay health care institutions for certain preventable conditions or errors that develop during hospital stay (Sanborn and Moody, 2009).
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Currently, statistics are bold in stating that 271 people die each day as a result of HAI and that about 1.7 million patients are suffering from HAI every year. To further cement the seriousness posed by HAI, research note that almost 75 per cent of patients rooms are contaminated with MRSA and VRE and that these bacteria are common everywhere on most equipment in hospital. On cost, estimates shows that HAI account for almost $40 billion in healthcare costs each year. Therefore it is necessary for precaution measures to be taken by key stakeholders to ensure that the rate of HAI is steadily reduced.
Hospital Acquired Infection for Submission (Surgical Site Infections-SSIs)
Increased surgical site infections continue to serve as a huge cost which has become a major issue in both Europe and America countries. For instance, every year 29 million surgical procedures are carried out and out of these, 2.6 per cent of patients get infected by SSIs while still recovering in Most Europe and American hospitals. When a patient get infected it becomes more expensive (3 times) to treat the infected patient and estimates shows that nosocomial infections costs many healthcare systems of Europe and USA close to 20 billion euros every year and the impacts have negatively affected the health economy of Europe and USA (Ramachandran, 2006). Surgical site infections (SSI) remain a real risk that is “associated with any surgical procedure and represent a significant burden in terms of patient morbidity and mortality, and cost to health services around the world” (Gottrup, Melling, and Hollander, 2005). Currently SSIs account for almost 16 per cent of all healthcare-acquired infections (HAI) and among the patients who have undergone surgery; SSIs constitute almost 40 per cent of HAI (Ramachandran, 2006). Numerous risk factors have been identified to be the major influencers to the development of SSIs and hence any adequate in-depth knowledge and awareness will provide and foster effective preventive strategies (Gottrup, Melling, and Hollander, 2005). To this end, the need for “assessment tools such as the Centers for Disease Control definitions, ASEPSIS and the Southampton Wound Assessment Scale are needed to accurately identify and classify SSIs” (Gottrup, Melling, and Hollander, 2005).
Estimated costs of SSIs has proved to be somehow cumbersome but the existing well done studies have shown that the additional bed occupancy is the main noteworthy factor and that SSIs burden in many developed countries has led to an extended admission of patient in hospital (9.8 days) and this has been accompanied by an average costs of $ 325 a day. Many factors have been identified to be the major causes of SSIs and in a way they have been classified in three major categories: Surgical consideration; anaesthetic consideration; and patient-related factors (Gottrup, Melling, and Hollander, 2005). In all the cases the level of bacteria laden remain as the most important risk factor but the good news is modern technologies and subsequent use of prophylactic antibiotics continue to reduce this risk steadily.
The main surgical preventive techniques that have been identified in preventing the SSIs have been found to be affected by: skin preparation, where the skin is colonized by numerous types of bacteria; shaving; and lastly, wound closure process whereby the healing of an already closed surgical wounds depends o many factors such as technique used or the level of expertise employed.
Focus on SSIs is important in that most infections today are associated with surgical devices and other prosthetic materials and which in turn has presented a major treatment challenge to many acute care organizations. Therefore an overview of current treatment and management strategies for SSIs are needed which will aid in formulating and establishing programs that adequately solve the issues of SSIs as far as their treatment and management are concerned.
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